It's true that x-rays don't show everything that is going on in your knee, but a doctor as good as yours is can infer a lot from an exam and x-ray image without actually having to see it. There is a small chance they could have missed something when they looked at your knee, but there is hardly any chance at all they would miss something major enough to cause that much pain, if it was actually coming from your knee joint. Knee pain is the most frequent complaint of runners, yet the majority of knee pain sufferers I have worked with have clean x-rays and MRIs. Clearly, there is another possible cause. Doomed? I'll bet there are a lot of seasoned runners out there who wish they had your knees!
One important thing that top athletes often learn, is the big difference between having knee pain and having a knee problem. As Damien suggested, many knee pains are caused by something outside the knee. In fact, many doctors believe that most knee pain is caused outside the knee, but with malpractice insurance rates as high as they are, doctors are compelled to spend your time and insurance money checking for the most serious possibilities, so you won't sue them for missing anything. It's also what we expect them to do. I am very lucky that my job only involves checking for probable causes after doctors have ruled out the others, so I'll try to be your virtual assistant today. Based on what I see time and time again, your intermittent knee pain is most likely caused by one or more muscles, whose involvement with knee pain is well documented.
It looks like you managed to make it into your late forties without this problem, until you were recently bit by the running bug. I started competing in 5ks when I was about your age, and encountered lots of pains within my first few years as my body adapted to the sport. Many years later, I experience a lot less pain from running, now that I am in my late fifties. I hope that encourages you to continue on, as long as your doctors say you are healthy enough to run.
One thing that probably helped me in the early days, is that I did not start out my running career by hitting the pavement cold-turkey. After patiently listening to well-meaning advice that running was going to ruin my knees, I purchased a small mini-trampoline and began to jog in place on it for several minutes a day, working up to about a half-hour per session. I held on to a counter top nearby for stability, so I suppose you could compare the strategy to what they now call a "rebounder," which is a mini-trampoline with bars to hold onto. The idea was to condition my knees for impact before hitting the road.
Since I was on my feet most of the time anyway, a month or so of this activity gave me the confidence to test running on the pavement. I started with miles, not 5ks. My first and second mile attempts took me over 12.5 minutes to complete, and were much harder than jogging in place. I called my folks back home to say my goodbyes, just in case this activity would kill me, because it sure felt like it would. Over the months I was able to get into the 8s, and set my goals for a 7, which I eventually did, after running slower at longer distances, including the 5k.
I too would encounter knee pains along the way, sometimes limping through entire races. While that was a dumb thing to do, I eventually mended and continued my quest for a six minute mile. By the time I broke that mark a few times I had experienced a few more aches and pains, but it is most likely that all of these were related to running too fast or too far. Still, I was becoming stronger. Goals make us try very hard, and our failure to reach them can still result in beneficial adaptations, along with a lot of pain. I think that after trying several times to go beyond 2 miles without pain, you will succeed, but there are a few things I have learned along the way that I would like to share with you, about how these pains are often caused and how to handle them easily, so you can continue to train safely. Running hurt can make you run sloppy, and running sloppy can result in the kinds of real injuries you fear.
If I understand your post correctly, you have been running a lot of 5ks, either in training or competition, within a very short period of time. If you push your running muscles hard enough, you can cause enough minor damage to result in a major change in how a muscle, or group of muscles, functions - without actually tearing it, or causing any other visible damage. You may even force a change in how a small portion of a muscle contracts, which is enough to create a big difference in how it acts on a joint. The most important point I want to make, is that your brain can do a super job of making you FEEL pain in an area that may eventually suffer damage you CAN see, if you ignore or suppress the pain. This miracle can occur long before there is any real risk to your knee joint, so it is good that you are asking questions now, rather than toughing it out until it is too late to avoid surgery.
You mentioned a misstep. Did you slip on something, or were your muscles tired? While there may be a link between that incident and your pain, there may be no direct connection. Sore muscles can stop working properly without a misstep, after becoming vunerable for some other reason. When RRS critiqued your slo-mo video, did they note what kind of over-pronation they were talking about? A physical therapist like Damien can tell you a lot more about your body mechanics after viewing a slo-mo video. The hip muscles he mentioned can rotate your leg into a position that is not favorable for preventing excess motion of the foot, more stress on your knee, and tiring of the muscles that stabilize it.
Chances are very good that the over-pronation has taken a toll on some of your muscles, but the pain in your knee may not be directly related to that either. In my case, the knee that bothered me most was on my stronger leg. One thing I found out about that leg, but was in denial about for years, is that it appears to be a bit longer than my other leg. There are many reasons why this could be, but it turns out that most people's legs appear to be unequal in length, which may be why they tend to hurt a little more on one side than the other.
Another reason for one-sided injuries that runners frequently encounter, is the fact that most of the roads we run on are not perfectly level. If they were, rain water would pool up on them. Even if your legs were perfectly even, running on that slanted surface can produce the same results as a longer leg. The leg on the upward side (or the effectively longer leg) has to make some adaptations to avoid dragging the toe. This may involve some lateral movement and/or rotation of the leg that stresses the knee during this movement, and after impact when it has more work to do, before the knee is in its strongest position. The leg on the down side (or shorter leg) may have to lift a little further to keep you level, stressing the Achilles tendon more, which is what happened in my case.
What I decided to do, after years of experimentation with knee braces, ice packs, arch supports, and orthotics, was to settle on a minimalist fix to correct the leg length discrepancy. A thin, flat, tough gel sole in the shorter side equalized things to the point that I didn't have unequal injuries any more, since both of my legs now had exactly the same job to do, with no unequal work on either side. While all this helped to eliminate the cause, it was not the only thing I had to do to address the symptoms.
When a muscle, or a small portion of it - even a group of muscles - is compromised, they rarely forget this insult easily. Even if a runner takes a couple weeks off, as in your case, returning to the pavement often produces the same results, as if there had been no rest at all. This concept is what keeps therapists busy, that we have to train and condition our muscles to "learn" how to act. Once "they" learn something wrong (a lot of these adaptations are in the brain, not the muscle), that behavior has to be unlearned. The trick I have learned over the years is how to erase that muscle memory in order to allow it to function normally. In effect, you can "reset" the relationship between a muscle and the brain that controls its tension, and it's not hard to do.
Before you attack your muscles willy-nilly, it's a good idea to figure out which muscles may be causing the pain that feels like it is coming from your knee. First, you have to be specific about which part of your knee hurts, because at any given time, one or more of a dozen muscles may be directly controlling your knee pain. Fortunately for us, this happens in well researched, predictable patterns. Most of the visual therapeutic materials for mapping these pain patterns is copyrighted and can't be shown directly here, but I will do my best to discuss it in my own words so you can reap the benefits. Rest assured, I've paid big bucks for this knowledge!
Open this link as a visual aid, and you can press backspace or click the back/forward arrows in the upper left on your (PC compatible) keyboard and/or browser to flip back and forth between the images and this post... http://www.getbodysmart.com/ap/muscularsystem/legmuscles/menu/menu.html If you can bookmark it and open it up in a separate window, you can alt-tab to flip back and forth between this text and the visual aid link.
Some of the top muscular producers of back-of-knee pain are the upper fibers of the bulging upper calf muscle Gastrocnemius. It is special in that it controls both knee and ankle flexion, but performs most of these tasks most effectively when the knee is locked, because its reach spans both joints. When you are running, it helps initiate the upward movement of your heel as you leg moves rearward, after which it runs out of leverage. It performs a lot more work while standing or climbing, to lock the knee and keep you from falling forward (as when going down stairs). A tiny muscle that assists these actions (Plantaris) is located right in the back of the knee itself. Both muscles can produce knee pain where they are and farther down, the lower fibers of the Gastroc often producing pain all the way down in the the arch of the foot (one of the primary causes of arch pain). Another small muscle in the back of the knee, the Popliteus, goes from the rear of your Tibia to the outside bottom of your Femur. This strange arrangement is necessary to slightly rotate the knee joint and unlock it, after standing with knees straight. Sudden twisting movements can irritate it. You can see how this muscle's function allows the other two to flex the knee by unlocking the knee, and the "firing order" of these muscles changes, depending on what you are trying to do.
Another back-of-knee pain culprit is the powerful outer hamstring (Biceps Femoris), which would also be involved with rotating the leg outward, as many do during pronation. Unfortunately, many of us sit on it all day, which keeps it in a shortened state and starved for blood flow. All of the muscles I have mentioned so far can produce back-of-knee pain when you stand straight and lock the knee, because even though none of them perform this function, they are stretched to the max when you do. This is one of the true tests of whether or not they are sore. Gastroc and Plantaris are further stretched when you stand on your heels with toes up, knee locked.
Outer knee pain is often due to problems with the outer Quad (Vastus Lateralis), and running can really make this muscle painfully dysfunctional, without actually damaging it at all. Lots of people confuse pain in this muscle with ITB (Iliotibial Band) syndrome, since the ITB runs over top of it and attaches in a spot where this muscle often hurts most. When people think they are foam-rolling ITBS, the V. Lateralis is getting a treat underneath, and often is the reason the pain goes away. The ITB, which is blamed for many runners' knee pains, is actually best addressed by relaxing the Glutes and pelvic hip flexor/abductor Tensor Fasciae Latae, which is not the latest Starbucks sensation, but a narrow muscle on the front of the pelvis whose primary purpose is to keep the ITB tight, because a loose ITB is worthless. On the other hand, the inability of Gluteal and TFL muscles to relax can produce 24-hour pressure on the side of the knee, resulting in compromised tissue at that sight. The description of your symptoms, with knee pain after two miles, might point to TFL problems if you had been running for many years. I dont think that a few months of 5ks are enough insult to cause that much dysfunction in your ITB system, but it could hammer the sensitive outer Quad and the calf muscles (mentioned above) in very little time, because they are not used to this new kind of stress.
Front of knee pain that is not coming from the joint itself, is usually from your inner quad, the Vastis Medialis, which is known for creating the sensation that your knee is going to give out. Sometimes it actually does, though the apparent muscular weakness does not necessariy mean the muscle is actually weak, or has a neurological problem. It's usually because your brain will refuse to use it when it becomes sensitive from overtraining or other causes, and the lack of support can lead to a lot of falls. It doesn't take much to affect it in this way, but it is easy to fix.
Another quad muscle is the only one that spans both the hip and knee joints. Called the Rectus Femoris, it is on top of the others and runs straight up and down the top center of your thigh. The upper fibers can produce deep knee pain and discomfort that actually feels like debris under your kneecap. When people report these symptoms and scans come up empty, these upper fibers need to be checked and disarmed. The lower fibers can produce an aching pain above the knee. While this muscle does not have the disabling effect of the V. Medialis, there is nothing to exclude any number of these muscles from going down in a domino effect, multiplying your symptoms and probable solutions. Symptoms of "runner's knee" are often little more than bum Quads, but they can cause real knee damage if left to themselves.
Sometimes a slip or fall that spreads your legs can strain your Adductor muscles, which include Adductor Longus and Brevis. These are located up your inner thigh, but can send pain to the front of your knee, as well as to your groin. The Adductors also function as hip flexors, so your running can tire them until a simple misstep can finish them off. Once again, a muscle can become painful and dysfunctional without any actual damage being done. People may want to see actual physical damage or swelling when they feel pain, but most pain is invisible. Imagine how many cars would be on the road if the idiot lights came on after the damage was done. The early warning system in your body is even smarter than the one in your car.
Inner knee pain
This one can involve some of the muscles we have alreay covered. Two of the Quads, Vastus Medialis and Rectus Femoris, can be responsible for pain here, and though their health is important, there are other support muscles that can produce serious inner knee pain. Adductor Longus, which we covered above, can also be involved. Two long, skinny muscles that start on the inner knee, but run over and above the other muscles mentioned, like a couple of ropes, one to the outer hip (Sartorius), and one to the pubic bone (Gracilis), function as secondary hip flexors, but also abduct and adduct (respectively) your thigh at the hip. Both of them can shoot pain into the inner knee under stress, though they both tend to exhibit that pain along their length, which is the giveaway. Lots of people think they have medial meniscus problems, but wind up finding problems in some of these muscles. A clean scan is your cue.
Sartorius can be set off by a twisting slip or fall, or by hip flexor stretches. It can hurt while standing and feel better when sitting down, when it is relaxed.
Gracilis pain can be very persistent regardless of position, but can we walked out. Because it rides over the Adductors, it can become problematic when the other Adductors are in trouble, even if there was no trauma to the muscle itself. Muscles are often very sociable with each other, working in groups and backing up each others' problems in a pain-fest of sympathy strikes. Viewing these body parts as systems can save a lot of time over considering them separately.
Now that we have looked at a number of potential victims of whatever cause led to your pain, I will show you how I fix them so you can begin healing and continue training. Except in extreme cases, we are mostly made up of muscles, some of which are quiet and faithful servants like the heart, and some of which are quite sensitive, complaining at the slightest provocation. Most of the muscles you use to run are sturdy and pain free, but susceptible to overload and overuse. When the muscle, via its many nerves and specialized neurons, sends suspicious patterns of sensation back to the brain, it can result in a guarding reflex that tightens the muscle and makes it less useful. Even well-conditioned muscle can become exhausted to the point of failure to function, which is why our mightiest athletes often collapse in a heap. An elite marathoner may be forced to train easy for months after a win, but for most of us, the simple stresses of daily living, or moderate exercise, can cause similar dysfunction. As with our sports heroes, it is a mistake to assume that these muscles are not well trained just because they do not always work when we want them to. All muscles need recovery time, but just taking a break does not necessarily equal rest and recovery.
Unlike our brains, there are a number of muscles that do not get to rest and recover every night. The heart is a perfect example of this, but there are other muscles in the body we use to position ourselves for work, or hold posture, even while we are sleeping or sitting watching TV. If that weren't enough, our muscles are the main source of our body temperature, which is almost always higher than the surrounding air. They have to work to produce this heat. It's not unusual to wake from a long sleep even more sore than you were before, and we can never assume that our muscles are relaxing along with the rest of us. They may not complain all the time, but they may when we try to use them for a demanding task, like the sudden urge to run 5ks. It takes energy to move a single meter, but 5,000 of them in a row is an incredible amount of work. Sure, we feel great afterwards, and want to do it again, but that does not mean our muscles are not in need of a major va-cay. There is a lot of damage at the cellular level you cannot always feel, and it takes more than time to fix. The most important thing to know is that simple rest is not always the rest you need.
If you were to look at your recovering muscle cells under a microscope after vigorous exercise, and contrast them with what you might find in a world champion marathoner, you would see a difference in how these two types of muscles react to training. Depending on how fit you are, you would see varying degrees of smearing of muscle cells, as they rupture and are broken down to be reabsorbed into the blood stream. The longer you have been sedentary, the more of this reconstruction will result from even a modest amount of training, as your weaker, more economy-minded muscle cells are destroyed and replaced by stronger, hungrier ones. However, anyone at any level of fitness can have this process going on at any time. The fitter you become, the more abuse it will take to push your muscle to the point it locks up (or fails to function) and forces you to let the reconstruction take place. Two important messages I want you to take away from this are (1) the muscle does not need to be locked up to heal (it may even slow the process), and (2) it may remain locked up indefinitely until you unlock it with the proper therapy. Just resting, stretching, or exercising are not enough.
If you are like most of us in this forum, you are somewhere between the two extremes of fitness. Only the ones at the top of their game are going to be able to go out and run some easy 100 mile weeks to loosen up. The rest of us would be destroyed by that, so one man's meat is another's poison when it comes to exercise. You've got to start at point "A" and work through the entire alphabet of fitness to get to point "Z" without causing serious damage to yourself. Yes, there are a few examples of people who have gotten off the couch and run sub-3 marathons, but they have to have already been exceptionally fit for some reason, genetic or otherwise. In our species, we all start with muscle tissue that is mostly the same. The man who most recently held the world record for the marathon used to run 10k to school and back when he was a kid, and he is still an awful overpronator. His muscles are so strong he can do all kinds of crazy stuff and survive it. Bill Rodgers had a really short left leg, but back-to-back Boston championships. I, on the other hand, needed a small thin gel pad in my shoe to balance me out enough to even qualify for Boston as an old man. It doesn't mean we aren't capable of great feats of endurance, but that we will have to take a little more care of ourselves than that guy over there stretching his leg onto the roof of his car.
Let's go to work... If you have reviewed and researched the muscles I have discussed, we can start trying to fix them so they will become less painful first, more mobile second, more relaxed around the clock third, and eventually, healed and strong, ready for more aggressive training. If you go back to the home menu on that muscle tutorial I linked, you can check out the section on how mucles actually contract, which I will not re-create here. Most of the information you need to know to take proper care of your body is spread all over the place, and rarely all in one place. As always, they charge money for the good stuff. I will do my best to sum it up for you. First, an overview of the complete picture.
Muscles are referred to by names that give us a roadmap for locating them individually, but they are sometimes interwoven in ways that combine function, as in the Quads. Within these muscle organs are sometimes multiple bellies, different motor nerves, and sections of fibers that have slightly different functions and can produce different types of pain. Some spots in these muscles may feel painful to the touch, others only when pressed, and others may display pain in another part of the body when we press them or they are tight. There are many cases when there is no pain, but dysfunction, and cases when there is pain, but no dysfunction in a given area. Troubleshooting muscles can be like a walk through a House of Mirrors, but there is a certain logic to it if you have the patience to learn. Most healthcare professionals do not have the time to commit all of this minutia to memory. The only reason I have the time to go on like this, is it's the only part of healthcare I really have to concern myself with. What keeps me sane is that the application is thankfully, very broad.
There is a tremendous variety of symptoms that muscle tissue can display when it is not working right. I believe you are encountering one or more of these symptoms, even if there is something wrong that is out of my scope of practice. Painless structural flaws and painful myofascial pain often run concurrently, which can be quite misleading. In most cases, muscle pain (myofascial pain) involves a very small part of a muscle or the fascia that surrounds it. A small area is all it takes to disrupt normal operation of the entire muscle and cause it to stiffen or to contract weakly. You can find these spots by scanning your muscles for tight fibers. I usually check mine with my fingers and a little soap and water in the shower. It helps to better define what is lurking under the skin. You'll get better at this with experience, but starting now will equip you to deal with other "injuries" you will encounter as you continue your running.
Myofascial pain usually involves one or more areas in a muscles fiber(s) that contract involuntarily into a mass that may feel like a rubbery lump of varying size, sometimes shifting location or changing its tension as you press on it. These spots are sometimes warm to the touch, and exhibit increased electrical activity when measured by equipment for the purpose. They are easy enough to find that nobody really needs to put a scope on you to find them, although there have been some advanced imaging systems developed for the purpose. Such equipment would be more widely available if an interview and fingers weren't so much cheaper. While areas of contorted tissue will usually stand out a bit and feel sensitive to the touch, they will often "refer" their pain to the end of the muscle or beyond, depending on how the nerves are wired and the brain interprets them. Most pain patterns are common, repeatable, and due to the same portions of muscle being in spasm. You can usually take a given set of symptoms to the bank, as being caused a certain way.
Working on these spots does not involve much more than that. You simply need to find them, apply varying degrees of pressure depending on sensitivity, and hold that pressure long enough for the tight fibers to "melt" under your fingers. Sometimes a little circular movement helps, and sometimes static pressure is less irritating. Sometimes the order in which you address each area matters. You get better with practice, and often have to repeat these actions enough times to get plenty of that. Whether you need to repeat this, and the frequency of treatment, is often dependent on the length of time the syndrome has been present, its severity, how much subsequent rest from activity you are getting, and whether or not you can gently move the tissue to re-educate your brain about its potential for movement. Your brain has a lot to keep track of, and often allows such tissue to remain in a dysfunctional state until you bring it to your brain's attention, front and center. This means you must often confront a wee bit of pain, and sometimes a lot of it. I've had conditions that felt for all the world like a broken bone, and it is usually worst the first time you go in. A little patience soon tells the difference between a real injury and myofascial pain.
So, why is there such pain, and why might you feel it in your joints? There is a lot of settled science on the subject, but more to be learned about the exact chemistry and neurological component. Much of the problem has to do with the breakdown of tissue that we discussed earlier, and the need to stimuate increased circulation and evacuation of waste product. Any time there is microtrauma to tissues that are served by blood or lymphatic flow, the cells of your immune system are attracted to the area to begin the process of reconstruction. Unfortunately, the original pain and dysfunction is not enough to bring this action about. Part of the problem may be physical, in that there was possibly a small blockage that lead to the dysfunction in the first place, and we essentially "break" this up. There may also be the neuromuscular component, in which the brain's perception of sensation results in altering motor nerve activity. Part of the solution is without question psychological, since an intervention is being made. It is a well established fact that people are capable of psyching themselves into muscular dysfunction, and the further pain and damage it may cause. In this case, making something feel better accomplishes more than it would seem.
One thing is for sure: when muscle loses abnormal tension in any or all of its fibers, it rests better. The time off that you take, then accomplishes something. You sleep better, with the satisfaction that something has been changed. Your hands were in that tissue just as surely as if a scalpel had been used, without the great potential for damage more invasive procedures entail. While the fix is not always instantaneous, it often is. I have seen huge improvements in tone, function, and perceived pain within a few seconds. Most of the time, it is an ongoing process, as is the stress that leads to dysfunction in the first place. In my view, it is an ongoing reality, and required skill, of the athletic lifestyle.
Doctors take a Hippocratic oath to "do no harm." That means, if push comes to shove, they will usually advise you in such a way that you will not be encouraged to harm yourself. If a physician looks at a set of symptoms and follows a differential diagnosis, myofascial pain may be down the list of potential severity. It almost always is. The reason is obviously what can happen if they make the wrong call, and you go out and break your leg. Give them credit for scaring you away from that possibility sometimes. There could still be a problem caused by impingement of spinal nerves, and that can be teased out by working with a physical therapist. Based on the progression you report, the symptoms would have been likely to occur during other activities, if that were the case. Nerve-related pains can be brought on by activity, but activity is not necessary needed to bring on false nerve generated pains. Movement-only related activity is usually muscular in origin, but can still involve pressure on nerves. If you still have fears of structural flaws, an ultrasound image may be cheaper than an MRI, and there are dye-injected tests that reveal more detail if required.
The reason why your doc is so good, is that he has acheived enough comfort with his material that he does not need to do this as much, and has the integrity to avoid pumping your insurance money. If he tells you there is no medical problem, and that it will eventually go away on its own, he is probably right. What I have covered here, is the gap between an acute medical condition that requires aggressive treatment, and one that can be taken care of at home. Though thousands of pages of medical literature have been written on the subject, it usually does not meet the test of urgency required for acute care, and you often cannot get insurance to cover treatment without a special addendum to your policy. This bothers me enough that I spend a lot of time trying to teach people how to handle it themselves. I was once where you are now, but thanks to patience and a lot of research, not any more. It didn't take me all day to write this, and I still have time to enjoy the 15-miler I had planned for today. I'm sure you'll be able to do the same someday. I know this is a lot to cover on a Sunday afternoon. but I'm sure you'll do fine.
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